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STATE OF CALIFORNIX WATER RESOURCES CONTROL BOARD ^' <br /> Yll'�� <br /> � � m f IN^ <br /> FORM A: UNDERGROUND STORAGE TANK PROGRAM �o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> 1 , COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY/ ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑5 CHANGE OF INFORMATION ❑7 PERMANENTLY CLO ED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑6 TEMPORARY SITE CLOSURE O <br /> I. FACILITY/SITE INFORMATION & ADDRESS — (MUST BE COMPLETED) tD <br /> FACILITY/SIT AME pp CARE OF ADDRESS INFORMATION <br /> r ,I <br /> ADDRESS NEAREST CROSS STREET ✓Bmbialole ❑ PARTRUSIP D SIATE'AGBILY <br /> D CORPORATION D L!1CAL44ENCY D FMIL xSENCY <br /> 1/ ❑ INOMWAL ❑ CGNIY AGDO <br /> CITY NAME _ STATE ZIP CODE SITE PHONE a,WITH AREA CODE <br /> CS i j CA 3 <br /> TYPE OF BUSINESS: ❑2DISTRIBUTOR ❑ 4PROCESSOR ✓Box if INDIAN EPA 10 <br /> RESERVATION or AT <br /> HIS SI <br /> ❑ 1 GAS STATION ❑3 FARM ❑ 5 OTHER TRUSTLANDS ❑ AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS'. NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE a WITH AREA CODE <br /> II. PROPERTY OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> V� I� <br /> MAILING or STREET ADDRESS ✓Box to mcl,caie D PARTNERSHIP D STATE-AGENCY <br /> DCORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> �Or D INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE a,WITH AREA CODE <br /> A enl _3 <br /> III. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to mclicate D PARTNERSHIP D STATE-AGENCY <br /> r ❑ CORPORATION D LOCAL-AGENCY D FEDERAL-AGENCY <br /> VFeI30Q bZAC Cl INDIVIDUAL D COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODEPONE q,WITH AREA CODE <br /> E q5 _ <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ 11. 111.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY B JURISDICTION If AGENCY# FACILITY ID If M D7 TANKS at SITE <br /> I I I L4 I In 1 (0 111 1 1 1 L <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE a WITH AREA CODE <br /> 13 <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE <br /> LOCATION CODE CENSUS TRACT# SUPERVISOR-0�,,IITRICT CODE BUSINESS PLAN FILED DATE FILED �] <br /> a3.a3 & YES ❑ NO ❑ <br /> CHEGKM PERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY:/� <br /> 1 THIS FORM MUST BE ACCOMPANIED BY AT LEAST"'OR MORE TANK PERMIT FORM 'B'APPLICATION(S% I INI FAS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> \ 1 FORA!A(32-881 � ` 1 <br /> DATA PROCESSING COPY �� \`\�' <br />